Testing a Novel Deliberate Practice Intervention to Improve Diagnostic Reasoning in Trauma Triage
Authors: Deepika Mohan, Jonathan Elmer, Robert M. Arnold, Raquel M. Forsythe, Baruch Fischhoff, Kimberly Rak, Jaqueline L. Barnes, Douglas B. White
Journal: JAMA Network Open (2023)

Importance Diagnostic errors made during triage at nontrauma centers contribute to preventable morbidity and mortality after injury. Objective To test the feasibility, acceptability, and preliminary effect of a novel deliberate practice intervention to improve diagnostic reasoning in trauma triage. Design, Setting, and Participants This pilot randomized clinical trial was conducted online in a national convenience sample of 72 emergency physicians between January 1 and March 31, 2022, without follow-up. Interventions Participants were randomly assigned to receive either usual care (ie, passive control) or a deliberate practice intervention, consisting of 3 weekly, 30-minute, video-conferenced sessions during which physicians played a customized, theory-based video game while being observed by content experts (coaches) who provided immediate, personalized feedback on diagnostic reasoning. Main Outcomes and Measures Using the Proctor framework of outcomes for implementation research, the feasibility, fidelity, acceptability, adoption, and appropriateness of the intervention was assessed by reviewing videos of the coaching sessions and conducting debriefing interviews with participants. A validated online simulation was used to assess the intervention’s effect on behavior, and triage among control and intervention physicians was compared using mixed-effects logistic regression. Implementation outcomes were analyzed using an intention-to-treat approach, but participants who did not use the simulation were excluded from the efficacy analysis. Results The study enrolled 72 physicians (mean [SD] age, 43.3 [9.4] years; 44 men [61%]) but limited registration of physicians in the intervention group to 30 because of the availability of the coaches. Physicians worked in 20 states; 62 (86%) were board certified in emergency medicine. The intervention was delivered with high fidelity, with 28 of 30 physicians (93%) completing 3 coaching sessions and with coaches delivering 95% of session components (642 of 674). A total of 21 of 36 physicians (58%) in the control group participated in outcome assessment; 28 of 30 physicians (93%) in the intervention group participated in semistructured interviews, and 26 of 30 physicians (87%) in the intervention group participated in outcome assessment. Most physicians in the intervention group (93% [26 of 28]) described the sessions as entertaining and valuable; most (88% [22 of 25]) affirmed the intention to adopt the principles discussed. Suggestions for refinement included providing more time with the coach and addressing contextual barriers to triage. During the simulation, the triage decisions of physicians in the intervention group were more likely to adhere to clinical practice guidelines than those in the control group (odds ratio; 13.8, 95% CI, 2.8-69.6; P = .001). Conclusions and Relevance In this pilot randomized clinical trial, coaching was feasible and acceptable and had a large effect on simulated trauma triage decisions, setting the stage for a phase 3 trial. Trial Registration ClinicalTrials.gov Identifier: NCT05168579